Increasing Confidence and Competence when a Chemotherapy Spill Occurs: A Quality Improvement Project

Executive Summary Introduction:Nurses in the oncology setting frequently administer chemotherapy, which is classified as a hazardous drug (HD) with known toxic effects (Connor, MacKenzie,DeBord, Trout, & O’Callaghan,2016). When a chemotherapy spill occurs, the HD poses a significant risk to healthcare workers. In a national survey, 16% of nurses reported unintentional chemotherapy exposures from a splash or spill within the past year (Friese, Himes-Ferris, Fraiser, McCullagh & Griggs, 2012). High rates of unintended exposures highlight the need for intervention, in order to manage chemotherapy spills and maintain the safety of the healthcare staff. Problems and Purpose Statement: While hospital protocols and education exist for the management of chemotherapy spills, evidence shows that nurses inconsistently adhere to hospital spill protocols, and are ill-trained to safely manage HD spills (Boiano, Steege, & Sweeny, 2014; Friese et al., 2012). Therefore, a current practice gap exists between chemotherapy spill education, and nurse implementation of education into practice.The purpose of the quality improvement (QI) project was to increase oncology nurse competence and confidence when a chemotherapy spill occurs, through increasing oncology nurse education. Didactic and simulation-based education interventions aimed to empower nurses to have the resources and ability to keep themselves and their patients safe in the event of a chemotherapy spill. Methods: The design of the QI project utilized the Plan-Do-Study-Act (PDSA) framework in order to implement evidence-based, effective change. The project consisted of one complete PDSA cycle. The PDSA cycle consisted of an eight-hour didactic education and one chemotherapy spill simulation. Nurse confidence was measured using a mixed-method Likert scale and open-ended question survey. Competence was measured utilizing an observational checklist during the chemotherapy spill simulation. Results/Outcomes: The project objectives to increase nurse competence and confidence were not met within one PDSA cycle. The average pre-test confidence survey decreased, with only one participant showing a statistically significant increase (P= 0.005) in confidence after simulation. Qualitative data showed themes regarding safetyand ongoing simulation training. During simulation, nurses were observed touching the outside of the hazardous waste bag, and often needed prompted as to the next steps in the cleanup process, ultimately placing themselves and their patients at risk of drug exposure. Unanticipated findings revealed areas for process clarity and improvement like faulty equipment. Sustainability: Before nurses are able to act as first responders to a spill on the oncology unit, competence must be met through simulation, equipment must be made readily available, and responsibilities must be clearly delineated. The next QI cycle will benefit with the addition of other disciplines, including the Code Orange Team and EVS. Chemotherapy simulated spill scenario, pre-test post-test survey, and observational checklists were provided to facilitate the next PDSA cycle, which should be another simulated spill scenario with the same charge nurse participants. Implications: While the Washington state law (WAC, 2017) outlines a necessary eight-hour training in order to respond to a chemotherapy spill, the required training did not correlate to competence or confidence during the simulated spill scenario, which implies that additional training is necessary in order to maintain nurse and patient safety. Additionally, organizations should not correlate prior spill experience, nurse confidence, or prior work experience to competent performance. In order for organizations to best support nurse and patient safety in the event of a chemotherapy spill, ongoing simulation was unanimously suggested by the QI participants. Ongoing educational efforts must be prioritized by organizations in order to maintain staff and patient safety in the event of a chemotherapy spill